Cardiovascular Clinical Assessment



Cardiovascular Clinical Assessment


Mary E. Lough


Physical assessment of the patient with cardiovascular disease is a skill that must not be overlooked in the middle of all the technology of the critical care setting.1 Data collected from a thorough, thoughtful history taking and examination contribute to both the nursing and the medical decisions about therapeutic interventions.



History


Patient history is important because it provides data that contribute to diagnosis of cardiovascular disease and treatment plan. For a patient in acute distress, the history taking is shortened to just a few questions about the patient’s chief complaint, precipitating events, and current medications (Box 13-1). For a patient who is not in obvious distress, the history focuses on the following four areas:



Box 13-1   Data Collection


Cardiovascular History






Medical History




Adult




• Diseases and abnormalities



• Surgical history



• Allergies, especially to emergency medications (lidocaine, morphine), radiographic contrast agents, or iodine (shellfish)


• Recent dental work or infection






One of the unique challenges in cardiovascular assessment is identifying when “chest pain” is of cardiac origin and when it is not. The following safety information should always be considered:



• If any evidence of CAD or risk of heart disease exists, assume that the chest pain is caused by myocardial ischemia until proven otherwise.


• Questions to elicit the nature of the chest pain cover five basic areas: 1) quality, 2) location, 3) duration of pain, 4) factors that provoke the pain, and 5) factors that relieve the pain. Questions that may help elicit this information are listed in Table 13-1.



• Little correlation may exist between the severity of chest discomfort and the gravity of its cause. This is a result of the subjective nature of pain and the unique presentation of ischemic disease in women, older patients, and individuals with diabetes.


• Subjective descriptors vary greatly among individuals. Not all patients use the word “pain”; some may describe their problem as “pressure,” heaviness,” discomfort,” or “indigestion.”


• A correlation is not always present between the location of chest discomfort and its source because of referred pain. For example, in patients with gastroesophageal reflux disease (GERD), esophageal spasm can cause visceral substernal chest pain that radiates to the left arm and jaw and may be described by patients as “heartburn.”2


• Other nonpainful symptoms that may signal cardiac dysfunction are dyspnea, palpitations, cough, fatigue, edema, ischemic leg pain, nocturia, syncope, and cyanosis.


In a meta-analysis of the evaluation of stable, intermittent chest pain, a patient’s description of chest pain was found to be the most important predictor of underlying coronary disease.3 In the evaluation of acute chest pain, the 12-lead electrocardiogram (ECG) was the most useful bedside predictor for a diagnosis of ST-elevation myocardial infarction (STEMI).3



Physical Examination


A comprehensive physical assessment is fundamental to arriving at an accurate diagnosis. The nurse who has developed the skills of inspection, palpation, and auscultation can be confident when assessing patients with cardiovascular disease. Percussion, however, is not employed when assessing the cardiovascular system.



Inspection


Face


The face is observed for the color of the skin (i.e., cyanotic, pale, or jaundiced) and for an apprehensive or painful expression. The patient’s skin, lips, tongue, and mucous membranes are inspected for pallor or cyanosis. Central cyanosis is a bluish discoloration of the tongue and sublingual area. Multiracial studies indicate that the tongue is the most sensitive site for observation of central cyanosis, which must be recognized and treated as a medical emergency. Pulse oximetry, arterial blood gas analysis, and treatment with 100% oxygen must be instituted immediately.





Nail Beds and Cyanosis


The nail beds are inspected for signs of discoloration or cyanosis.4 Clubbing in the nail bed is a sign associated with long-standing central cyanotic heart disease or pulmonary disease with hypoxemia.4,5 “Clubbing” of the nail refers to a nail that has lost the normal angle between the finger and the nail root; the nail becomes wide and convex. The terminal phalanx of the finger also becomes bulbous and swollen.6 Clubbing is rare and is a sign of severe central cyanosis (Fig. 13-1). Peripheral cyanosis, a bluish discoloration of the nail bed, is seen more commonly. Peripheral cyanosis results from a reduction in the quantity of oxygen in the peripheral extremities from arterial disease or decreased cardiac output (CO). Clubbing never occurs as a result of peripheral cyanosis.




Lower Extremities


Legs are inspected for signs of peripheral arterial or venous vascular disease. The visible signs of peripheral arterial vascular disease include pale, shiny legs with sparse hair growth. Recent guidelines indicate that many individuals, especially women, can have peripheral atherosclerosis without obvious signs or symptoms.7 Venous disease causes edema of the limb, with deep red rubor, brown discoloration, and, frequently, leg ulceration. A comparison of typical assessment findings in arterial and venous diseases is presented in Table 13-2.







Jugular Veins


The jugular veins of the neck are inspected for a noninvasive estimate of intravascular volume and pressure. The internal jugular veins are observed for jugular vein distention (JVD) (Fig. 13-2; Box 13-2). JVD is caused by an elevation in central venous pressure (CVP). This occurs with fluid volume overload, right ventricular dysfunction, pericardial effusion, or any condition that elevates right atrial pressure.9,10 The right internal jugular vein can be palpated for measurement of CVP in centimeters of water (Fig. 13-3; Box 13-3). Bedside ultrasound is also used to evaluate JVD and estimate CVP.11







Abdominojugular Reflux


The abdominojugular reflux sign can assist with the diagnosis of right ventricular failure. This noninvasive test is used in conjunction with measurement of JVD. The procedure for assessing abdominojugular reflux is described in Box 13-4. A positive abdominojugular reflux sign is an increase in the jugular venous pressure (CVP equivalent) of 4 cm or more sustained for at least 15 seconds.12




Thoracic Reference Points


The thoracic cage is divided with imaginary vertical lines (sternal, midclavicular, axillary, vertebral, and scapular), and the intercostal spaces are divided by imaginary horizontal lines to serve as reference points in locating or describing cardiac findings (Fig. 13-4). The ribs are numbered from 1 (the first rib below the clavicle) to 12. The intercostal space below each rib is given the same number as the rib that lies above it. The second rib is the easiest to locate because it is attached to the sternum at the angle of Louis. This angle (also called the sternal angle) is the bony ridge on the sternum that lies approximately 2 inches below the sternal notch (see Fig. 13-4A). After the second rib has been located, it can be used as a reference point to count off the other ribs and intercostal spaces.





Palpation


Palpation is a technique that uses the sense of touch in the tips of the fingers and the palm of the hand.





Brachial, Ulnar, and Radial Pulses


The brachial pulse is assessed by gently palpating the inner aspect of the slightly bent elbow with the fingers. The radial pulse is palpated in the medial area of the wrist (thumb side). The ulnar artery is palpated at the opposite side of the wrist (little finger side). The radial and ulnar arterial pulses must be assessed before an arterial line is inserted; this test, known as the Allen test, is described in Box 13-6.


Oct 29, 2016 | Posted by in NURSING | Comments Off on Cardiovascular Clinical Assessment

Full access? Get Clinical Tree

Get Clinical Tree app for offline access